Organization
STATE OF MISSOURI
Active
Parent organization
STATE OF MISSOURI
Other names
St. Louis Developmental Disabilities Treatment Center
Organization subpart
Yes
Provider details
NPI number
Legal business name
STATE OF MISSOURI
Authorized official
MOLLY JANE BOECKMANN (DIRECTOR OF ADMINISTRATIVE SERVICES)
(573) 751-4055
Entity
Organization
Contact information
Practice address
22 MARR LN, SAINT CHARLES, MO 63303-9000
(314) 340-6702
(314) 340-6724
Mailing address
1706 E ELM ST, JEFFERSON CITY, MO 65101-4130
(573) 751-3398
(573) 526-4560
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
—
—
208800000X
Urology Physician
—
—
208D00000X
General Practice Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
501500011
—
MO
Enumeration date
05/20/2006
Last updated
10/20/2020
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